ST-segment elevation in conditions other than acute myocardial infarction

Persistent convex ST-segment elevation in a patient with a history of prior intracerebral haemorrhage

Management of patients with acute chest pain poses a significant challenge in identifying those requiring urgent coronary reperfusion. Electrocardiogram (ECG) constitutes the cornerstone in making prompt clinical decisions by identifying ST-segment elevation, commonly associated with ST-segment elevation myocardial infarction. It is important to note that ST-segment elevation can also be a manifestation of various cardiac and non-cardiac conditions, from acute myocarditis, early repolarization syndrome, acute pericarditis, and left bundle branch block to unknown origins. The similarity of ECG changes among these conditions complicates clinical differential diagnosis, necessitating a detailed medical history and thorough examinations. Here, we presented a case of a 52-year-old female with chest pain and unidentified convex ST-segment elevation. Considering the negative emergent coronary angiography results, normal echocardiography, and long-lasting ST-segment elevation for the following 1 year, the final diagnosis was non-myocardial infarction, probably related to a prior cerebral haemorrhage.

ST segment and T wave abnormalities: A narrative review

INTRODUCTION

The electrocardiogram (ECG) is a valuable tool for interpreting ventricular repolarization. This article aims to broaden the diagnostic scope beyond the conventional ischemia-centric approach, integrating an understanding of pathophisiological influences on ST-T wave changes.

METHODS

A review was conducted on the physiological underpinnings of ventricular repolarization and the pathophisiological processes that can change ECG patterns. The research encompassed primary repolarization abnormalities due to uniform variations in ventricular action potential, secondary changes from electrical or mechanical alterations, and non-ischemic conditions influencing ST-T segments.

RESULTS

Primary T waves are characterized by symmetrical waves with broad bases and variable QT intervals, indicative of direct myocardial action potential modifications due to ischemia, electrolyte imbalances, and channelopathies. Secondary T waves are asymmetric and often unassociated with significant QT interval changes, suggesting depolarization alterations or changes in cardiac geometry and contractility.

CONCLUSION

We advocate for a unified ECG analysis, recognizing primary and secondary ST-T changes, and their clinical implications. Our proposed analytical framework enhances the clinician's ability to discern a wide array of cardiac conditions, extending diagnostic accuracy beyond myocardial ischemia.

Self-supervised deep representation learning of a foundation transformer model enabling efficient ECG-based assessment of cardiac and coronary function with limited labels

Background: Although deep learning methods have shown great promise for identification of structural and functional cardiac abnormalities using electrocardiographic data, these methods are data hungry, posing a challenge for critically important tasks where ground truth labels are relatively scarce. Impaired coronary microvascular and vasomotor function is difficult to identify with standard clinical methods of cardiovascular testing such as coronary angiography and noninvasive single photon emission tomography (SPECT) myocardial perfusion imaging (MPI). Gold standard data from positron emission tomography (PET) are gaining emphasis in clinical guidelines but are expensive and only available in relatively limited centers. We hypothesized that signals embedded within resting and stress electrocardiograms (ECGs) identify individuals with microvascular and vasomotor dysfunction. Methods: We developed and pretrained a self-supervised foundation vision transformer model using a large database of unlabeled ECG waveforms (N=800,035). We then fine-tuned the foundation model for two clinical tasks: the difficult problem of identifying patients with impaired myocardial flow reserve (AI-MFR), and the relatively easier problem of detecting impaired LVEF (AI-LVEF). A second ECG database was labeled with task-specific annotations derived from quantitative PET MPI (N=4167). Diagnostic accuracy of AI predictions was tested in a holdout set of patients undergoing PET MPI (N=1031). Prognostic evaluation was performed in the PET holdout cohort, as well as independent cohorts of patients undergoing pharmacologic or exercise stress SPECT MPI (N=6635). Results: The diagnostic accuracy of AI-MFR with SSL pretraining increased significantly compared to de novo supervised training (AUROC, sensitivity, specificity: 0.758, 70.1%, 69.4% vs. 0.632, 66.1%, 57.3%, p < 0.0001). SSL pretraining also produced a smaller increase in AI-LVEF accuracy (AUROC, sensitivity, specificity: 0.946, 89.4%, 85.9% vs. 0.918, 87.6%, 82.5%, p < 0.02). Abnormal AI-MFR was found to be significantly associated with mortality risk in all three test cohorts (Hazard Ratio (HR) 2.61 [95% CI 1.83, 3.71], p < 0.0001, PET cohort; HR 2.30 [2.03, 2.61], p < 0.0001, pharmacologic stress SPECT cohort; HR 3.76 [2.36, 5.99], p < 0.0001, exercise stress SPECT cohort). Conclusion: SSL pretraining of a vision transformer foundation model enabled identification of signals predictive of impaired MFR, a hallmark of microvascular and vasomotor dysfunction, and impaired LV function in resting and stress ECG waveforms. These signals are powerful predictors of prognosis in patients undergoing routine noninvasive stress testing and could enable more efficient diagnosis and management of these common conditions.

Compared with physician overread, computer is less accurate but helpful in interpretation of electrocardiography for ST-segment elevation myocardial infarction

INTRODUCTION

Previous studies have demonstrated varying sensitivity and specificity of computer-interpreted electrocardiography (CIE) in identifying ST-segment elevation myocardial infarction (STEMI). This study aims to evaluate the accuracy of contemporary computer software in recognizing electrocardiography (ECG) signs characteristic of STEMI compared to emergency physician overread in clinical practice.

MATERIAL AND METHODS

In this retrospective observational single-center study, we reviewed the records of patients in the emergency department (ED) who underwent ECGs and troponin tests. Both the Philips DXL 16-Lead ECG. Algorithm and on-duty emergency physicians interpreted each standard 12‑lead ECG. The sensitivity and specificity of computer interpretation and physician overread ECGs for the definite diagnosis of STEMI were calculated and compared.

RESULTS

Among the 9340 patients included in the final analysis, 133 were definitively diagnosed with STEMI. When "computer-reported infarct or injury" was used as the indicator, the sensitivity was 87.2% (95% CI 80.3% to 92.4%) and the specificity was 86.2% (95% CI 85.5% to 86.9%). When "physician-overread STEMI" was used as the indicator, the sensitivity was 88.0% (95% CI 81.2% to 93.0%) and the specificity was 99.9% (95% CI 99.8% to 99.9%). The area under the receiver operating characteristic curve for physician-overread STEMI and computer-reported infarct or injury were 0.939 (95% CI 0.907 to 0.972) and 0.867 (95% CI 0.834 to 0.900), respectively.

CONCLUSIONS

This study reveals that while the sensitivity of the computer in recognizing ECG signs of STEMI is similar to that of physicians, physician overread of ECGs is more specific and, therefore, more accurate than CIE.

Common ECG interpretation software mistakes. Part I: False reporting of myocardial infarction

The purpose of computerized analysis of electrocardiograms (ECGs) is to provide rapid interpretation in places where ECG experts are not available, and to save physician time for all providers. For the most part, contemporary interpretation algorithms perform remarkably well and offer correct diagnoses of common ECG abnormalities. Diagnostic accuracy for myocardial ischemia and infarction is reasonably good but with these conditions, false positive and false negative readings can be disastrous. It is essential, therefore, that computerized statements be over-read by trained physicians. A three-part mini-series is intended to provide assistance to quickly recognize and correct common interpretation software mistakes. This first chapter presents interpretation errors that falsely indicate myocardial infarction.

Longitudinal ECG changes among adults with HIV in Tanzania: A prospective cohort study

The prevalence of cardiovascular disease (CVD) is rising among people with HIV (PWH) in sub-Saharan Africa (SSA). Despite the utility of the electrocardiogram (ECG) in screening for CVD, there is limited data regarding longitudinal ECG changes among PWH in SSA. In this study, we aimed to describe ECG changes over a 6-month period in a cohort of PWH in northern Tanzania. Between September 2020 and March 2021, adult PWH were recruited from Majengo HIV Care and Treatment Clinic (MCTC) in Moshi, Tanzania. Trained research assistants surveyed participants and obtained a baseline ECG. Participants then returned to MCTC for a 6-month follow-up, where another ECG was obtained. Two independent physician adjudicators interpreted baseline and follow-up ECGs for rhythm, left ventricular hypertrophy (LVH), bundle branch blocks, ST-segment changes, and T-wave inversion, using standardized criteria. New ECG abnormalities were defined as those that were absent in a patient's baseline ECG but present in their 6-month follow-up ECG. Of 500 enrolled participants, 476 (95.2%) completed follow-up. The mean (± SD) age of participants was 45.7 (± 11.0) years, 351 (73.7%) were female, and 495 (99.8%) were taking antiretroviral therapy. At baseline, 248 (52.1%) participants had one or more ECG abnormalities, the most common of which were LVH (n = 108, 22.7%) and T-wave inversion (n = 89, 18.7%). At six months, 112 (23.5%) participants developed new ECG abnormalities, including 40 (8.0%) cases of new T-wave inversion, 22 (4.6%) cases of new LVH, 12 (2.5%) cases of new ST elevation, and 11 (2.3%) cases of new prolonged QTc. Therefore, new ECG changes were common over a relatively short 6-month period, which suggests that subclinical CVD may develop rapidly in PWH in Tanzania. These data highlight the need for additional studies on CVD in PWH in SSA and the importance of routine CVD screening in this high-risk population.

ST-Segment Elevation: An Unexpected Culprit

The clinical presentation of pulmonary embolism (PE) and acute coronary syndrome can be similar. We report a case of a patient presenting with antero-septal ST-segment elevation after cardiac arrest, found to have acute-PE-mimicking ST-segment elevation myocardial infarction (STEMI), treated with aspiration thrombectomy and catheter-directed thrombolysis (CDT). A 78-year-old man was admitted with dyspnea, chest pain and tachycardia. During evaluation, cardiac arrest in pulseless electrical activity was documented. Advanced life support was started immediately. ECG post-ROSC revealed ST-segment elevation in V1-V4 and aVR. Echocardiography showed normal left ventricular function but right ventricular (RV) dilation and severe dysfunction. The patient was in shock and was promptly referred to cardiac catheterization that excluded significant CAD. Due to the discordant ECG and echocardiogram findings, acute PE was suspected, and immediate invasive pulmonary angiography revealed bilateral massive pulmonary embolism. Successful aspiration thrombectomy was performed followed by local alteplase infusion. At the end of the procedure, mPAP was reduced and blood pressure normalized allowing withdrawal of vasopressor support. Twenty-four-hour echocardiographic reassessment showed normal-sized cardiac chambers with preserved biventricular systolic function. Bedside echocardiography in patients with ST-segment elevation post-ROSC is instrumental in raising the suspicion of acute PE. In the absence of a culprit coronary lesion, prompt pulmonary angiography should be considered if immediately feasible. In these cases, CDT and aspiration in high-risk acute PE seem safe and effective in relieving obstructive shock and restoring hemodynamics.

Considerations on the Management of Acute Postoperative Ischemia After Cardiac Surgery: A Scientific Statement From the American Heart Association

Acute postoperative myocardial ischemia (PMI) after cardiac surgery is an infrequent event that can evolve rapidly and become a potentially life-threatening complication. Multiple factors are associated with acute PMI after cardiac surgery and may vary by the type of surgical procedure performed. Although the criteria defining nonprocedural myocardial ischemia are well established, there are no universally accepted criteria for the diagnosis of acute PMI. In addition, current evidence on the management of acute PMI after cardiac surgery is sparse and generally of low methodological quality. Once acute PMI is suspected, prompt diagnosis and treatment are imperative, and options range from conservative strategies to percutaneous coronary intervention and redo coronary artery bypass grafting. In this document, a multidisciplinary group including experts in cardiac surgery, cardiology, anesthesiology, and postoperative care summarizes the existing evidence on diagnosis and treatment of acute PMI and provides clinical guidance.

Gastric Dilatation Masquerading as Anterolateral ST-Elevation Myocardial Infarction

A variety of noncardiac conditions mimic the electrocardiographic changes of ST-elevation myocardial infarction (STEMI). Therefore, a physician must maintain a high index of suspicion when evaluating ST-segment elevation (STE). We present a case of epigastric pain secondary to ileus and gastric dilatation masquerading as anterolateral STEMI on an electrocardiogram (ECG). The STE promptly resolved following laparotomy. To the best of our knowledge, this is the first case of anterolateral STE secondary to gastric dilatation.

Cardiac tamponade-mediated generalized coronary vasospasm presenting as an inferior ST-segment elevation myocardial infarction: a case report

Background

Coronary vasospasm is a rare cause of ST-segment elevation myocardial infarction (STEMI) and can be precipitated by numerous inciting factors including endogenous catecholamines. Differentiating coronary vasospasm from an acute atherothrombotic event is diagnostically challenging and requires a careful clinical history combined with electrocardiographic and angiographic abnormalities to make the diagnosis and guide therapy.

Case Summary

We report a case of cardiogenic shock secondary to cardiac tamponade leading to an endogenous catecholamine surge resulting in profound arterial vasospasm and STEMI. The patient presented with chest pain and inferior ST segment elevations prompting emergent coronary angiography, demonstrating subtotal occlusion of the right coronary artery, severe proximal left anterior descending coronary artery stenosis, and diffusely stenosed aortoiliac vessels. Emergent transthoracic echocardiogram revealed a large pericardial effusion and hemodynamics consistent with cardiac tamponade. Pericardiocentesis resulted in dramatic hemodynamic improvement with immediate normalization of ST segments. Repeat coronary angiography performed one day later showed no angiographically significant coronary or peripheral arterial stenosis.

Discussion

This is the first reported case of simultaneous coronary and peripheral arterial vasospasm presenting as inferior STEMI caused by endogenous catecholamines from cardiac tamponade. Several clues suggest coronary vasospasm including the discordant electrocardiography (ECG) and coronary angiographic findings as well as diffusely stenosed aortoiliac vessels. Diffuse vasospasm was confirmed when repeat angiography performed after pericardiocentesis demonstrated angiographic resolution of coronary and peripheral arterial stenosis. Though rare, circulating endogenous catecholamines resulting in diffuse coronary vasospasm may present as STEMI and should be considered based on the clinical history, ECG findings, and coronary angiography.

Cardiac metastasis mimicking STEMI-impact of point-of-care ultrasound on clinical decision-making: A case report

Introduction

The manifestations of cardiac metastases are extremely variable depending on their location and extension.

Case presentation

A 62-year-old man was admitted to the cardiac emergency department presenting with chest pain, worsening shortness of breath and palpitations. He had a history of esophageal squamous cell carcinoma treated with chemoradiotherapy, and he was not diagnosed with cardiovascular disease before. The electrocardiogram showed significant ST-segment elevations in leads II, III, and aVF. Initially, the patient was diagnosed with ST-segment elevation myocardial infarction. A cardiac point-of-care ultrasound was performed immediately revealing two large heterogeneous masses in the left ventricular wall and the apex, which changed the diagnosis and the management strategy. There was no significant change in serial cardiac biomarkers in the setting of persistent STE. Thoracic computed tomography and cardiac magnetic resonance confirmed that the patient was suffering from cardiac and lung metastases.

Conclusion

ECG findings of localized and prolonged STE without Q waves or changes in biomarkers may suggest myocardial tumor invasion, especially in the cancer setting. Cardiac point-of-care ultrasound is an effective, convenient, noninvasive imaging modality to guide real-time clinical decision-making.

Extreme Hyperthermia Due to Methamphetamine Toxicity Presenting As ST-Elevation Myocardial Infarction on EKG: A Case Report Written With ChatGPT Assistance

We present a case report of a 37-year-old male who presented to the emergency department with altered mental status and electrocardiographic changes suggestive of an ST-elevation myocardial infarction (STEMI). He was ultimately diagnosed with extreme hyperthermia, secondary to drug use, which was managed promptly with supportive measures resulting in a successful outcome. This case highlights the importance of considering drug-induced hyperthermia as a potential cause of altered mental status and EKG changes in patients, especially in those with a history of drug abuse.

An Uncommon Cause of Acute Chest Pain

This case report describes a patient in their 50s with 20 minutes of substernal chest pain radiating to the left shoulder and back, which was accompanied by shortness of breath and sweating.

Three, dynamic variants of ST segment elevations in a patient with osteosarcoma and cardiac metastasis

In the right clinical setting, ST segment elevation (STE) on electrocardiogram (ECG) is most concerning for acute injury due to transmural myocardial ischemia. This frequently points to significant epicardial coronary artery disease, mandating emergent cardiac intervention. In rare cases, cardiac metastases may cause transient STE. We present a case of a 28-year-old male patient with metastatic osteosarcoma with STE in three different ECG territories over ten months. Several transient, dynamic patterns of STE were noted: anteroseptal leads concerning for acute injury with reciprocal ST depressions in inferior leads, lateral leads, inferior leads with reciprocal ST depression in lateral leads, followed by STE again in lateral leads. Given the patient's young age, absence of cardiac history or symptoms, personal preference, bleeding risk, and cancer prognosis, cardiac catheterization was never pursued. We present this case to remind providers to include metastatic cancer in the differential diagnosis of STE on ECG, and that these changes can be dynamic.

Riding the wave: a quantitative report of electrocardiogram utilization for myocardial infarction confirmation

The purpose of this study was to generate a quantitative profile of electrocardiograms (ECGs) for confirming surgical success of permanent coronary artery ligation. An ECG was recorded at baseline, and 0, 1, and 5 min after ligation and analyzed using iWorkx LabScribe software. Cohort 1 (C57Bl6/J, n = 8/sex) was enrolled to determine ECG characteristics that were confirmed in cohort 2 (C57Bl6/J, n = 6/sex; CD8-/-n = 6 males/4 females). Of the 16 mice in cohort 1, 12 (6/sex) had an infarct ≥35% and four mice (2/sex) had <35% based on 2,3,5-triphenyltetrazolium chloride staining. After ligation, the QRS complex and R-S amplitude were significantly different compared with baseline. No differences were observed in the R-S amplitude between mice with infarcts ≥35% versus <35% at any time point, whereas the QRS complex was significant 1 min after ligation. Receiver operating characteristic (ROC) curve linked changes in the QRS complex but not the R-S amplitude at 1 and 5 min with surgical success. Data were normalized to baseline values to calculate fold change. ROC analysis of the normalized QRS data indicated strong sensitivity and specificity for infarcts ≥35%; normalized R-S amplitude remained nonsignificant. With a cutoff generated by ROC analysis of cohort 1 (>80% sensitivity; >90% specificity), the non-normalized QRS complex of cohort 2 had an 86% success rate (2 false positives; 1 false negative). The normalized data had a 77% success rate (2 false positives; 3 false negatives). Neither sex nor genotype was associated with false predictions (P = 0.18). Our data indicate that the area under the QRS complex 1 min after ligation can improve reproducibility in MI surgeries.NEW & NOTEWORTHY Our study describes a quantitative method for using an electrocardiogram (ECG) to determine which animals have infarcts that reflect coronary artery ligation. Using a quantitative ECG, investigators will have the benefit of having real-time feedback during the procedure, which will ultimately decrease the amount of time investigators spend performing experiments. This overall increase in efficiency will help investigators decrease animal numbers used due to better surgical outcomes.

Associations between electrocardiogram and carotid ultrasound parameters: a healthy chinese group study

Background: Electrocardiogram (ECG) and carotid ultrasound (CUS) are important tools for the diagnosis and prediction of cardiovascular disease (CVD). This study aimed to investigate the associations between ECG and CUS parameters and explore the feasibility of assessing carotid health with ECG.

Methods: This cross-sectional cohort study enrolled 319 healthy Chinese subjects. Standard 12-lead ECG parameters (including the ST-segment amplitude [STA]), CUS parameters (intima-media thickness [IMT] and blood flow resistance index [RI]), and CVD risk factors (including sex, age, and systolic blood pressure [SBP]) were collected for analysis. Participants were divided into the high-level RI group (average RI ≥ 0.76, n = 171) and the normal RI group (average RI < 0.76, n = 148). Linear and stepwise multivariable regression models were performed to explore the associations between ECG and CUS parameters.

Results: Statistically significant differences in sex, age, SBP, STA and other ECG parameters were observed in the normal and the high-level RI group. The STA in lead V₃ yielded stronger significant correlations (r = 0.27–0.42, p < 0.001) with RI than STA in other leads, while ECG parameters yielded weak correlations with IMT (|r| ≤ 0.20, p < 0.05). STA in lead V₂ or V₃, sex, age, and SBP had independent contributions (p < 0.01) to predicting RI in the stepwise multivariable models, although the models for IMT had only CVD risk factors (age, body mass index, and triglyceride) as independent variables. The prediction model for RI in the left proximal common carotid artery (CCA) had higher adjusted R² (adjusted R² = 0.31) than the model for RI in the left middle CCA (adjusted R² = 0.29) and the model for RI in the right proximal CCA (adjusted R² = 0.20).

Conclusion: In a cohort of healthy Chinese individuals, the STA was associated with the RI of CCA, which indicated that ECG could be utilized to assess carotid health. The utilization of ECG might contribute to a rapid screening of carotid health with convenient operations.

Clinical and electrocardiographic characteristics in patients with fulminant myocarditis

Background

The purpose of this study was to evaluate clinical and electrocardiographic characteristics in patients with fulminant myocarditis.

Methods

A total of 72 patients were divided into three groups: pericarditis (control: n = 25), acute myocarditis (n = 27), and fulminant myocarditis (n = 20). Patients' characteristics and electrocardiograms on admission were retrospectively analyzed in the three groups.

Results

BNP levels in the fulminant group were significantly higher than those in the other two groups. ST elevation was observed at lead aVR in the fulminant myocarditis group, whereas ST depression was observed at lead aVR in the other groups (p = .001). The maximum degree of ST elevation among the three groups was similar. However, the number of ST‐elevation leads in the fulminant myocarditis group was significantly lower than that in the other groups (p = .004). The voltage of R wave in lead V5 in the fulminant myocarditis group was significantly lower than that in the other groups (p = .005). Moreover, in the Cabrera sequence, the prevalence of ST elevation in the inferior leads, aVR, and V3–V6 in the fulminant myocarditis group was significantly or nearly significantly lower than that in the other groups.

Conclusions

In fulminant myocarditis, ST‐segment elevation was observed in lead aVR, and contrarily, the number and extent of ST‐segment elevation and R wave voltage were smaller than those in the other groups. These results suggest that the number of myocytes with maintained action potential may be reduced following progressive myocardial damage and interstitial edema due to severe inflammation.

Utility of prehospital electrocardiogram interpretation in ST-segment elevation myocardial infarction utilizing computer interpretation and transmission for interventional cardiologist consultation

Objectives

We examined the appropriateness of prehospital cardiac catheter laboratory activation (CCL‐A) in ST‐segment elevation myocardial infarction (STEMI) utilizing the University of Glasgow algorithm (UGA) and remote interventional cardiologist consultation.

Background

The incremental benefit of prehospital electrocardiogram (PH‐ECG) transmission on the diagnostic accuracy and appropriateness of CCL‐A has been examined in a small number of studies with conflicting results.

Methods

We identified consecutive PH‐ECG transmissions between June 2, 2010 and October 6, 2016. Blinded adjudication of ECGs, appropriateness of CCL‐A, and index diagnoses were performed using the fourth universal definition of MI. The primary outcome was the appropriate CCL‐A rate. Secondary outcomes included rates of false‐positive CCL‐A, inappropriate CCL‐A, and inappropriate CCL nonactivation.

Results

Among 1088 PH‐ECG transmissions, there were 565 (52%) CCL‐As and 523 (48%) CCL nonactivations. The appropriate CCL‐A rate was 97% (550 of 565 CCL‐As), of which 4.9% (n = 27) were false‐positive. The inappropriate CCL‐A rate was 2.7% (15 of 565 CCL‐As) and the inappropriate CCL nonactivation rate was 3.6% (19 of 523 CCL nonactivations). Reasons for appropriate CCL nonactivation (n = 504) included nondiagnostic ST‐segment elevation (n = 128, 25%), bundle branch block (n = 132, 26%), repolarization abnormality (n = 61, 12%), artefact (n = 72, 14%), no ischemic symptoms (n = 32, 6.3%), severe comorbidities (n = 26, 5.2%), transient ST‐segment elevation (n = 20, 4.0%), and others.

Conclusions

PH‐ECG interpretation utilizing UGA with interventional cardiologist consultation accurately identified STEMI with low rates of inappropriate and false‐positive CCL‐As, whereas using UGA alone would have almost doubled CCL‐As. The benefits of cardiologist consultation were identifying “masquerading” STEMI and avoiding unnecessary CCL‐As.

Profound Anterior ST-Segment Elevation in a Patient with Lung Cancer and Echocardiographic Evidence of Right Ventricle Metastasis

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Malignant cardiac metastasis can manifest as ECG abnormality masquerading as STEMI.

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Extensive RV wall metastasis may cause anterior STE elevation.

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Echocardiography is the modality of first choice in diagnosing cardiac metastasis.

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Timely point-of-care ultrasound is important in critical clinical decision-making.

Hypercalcemia as the Initial Presentation of Acute T-cell Leukemia/Lymphoma

Adult T-cell leukemia/lymphoma (ATLL) is a T-cell malignancy that generally presents with widespread involvement of lymph nodes, peripheral blood, and/or skin. It is an uncommon malignancy linked to the human T-lymphotropic virus 1 (HTLV-1). Herein, we present a case of ATLL that was diagnosed after a patient presented to our hospital with nonspecific symptoms of fatigue and weakness and was subsequently found to have hypercalcemia secondary to his blood malignancy. We engage in a discussion of the etiology, epidemiology, and management of patients with this rare malignancy as well as the mechanisms that result in hypercalcemia.

Hypophosphatemia causing ST elevation in a critically ill noncardiac surgery postoperative patient

The patient is a 73-year-old female with peripheral vascular disease, coronary artery disease, and systemic lupus erythematosus, who underwent mesenteric artery bypass surgery. She suffered from a pneumonia after surgery, causing acute hypoxic respiratory failure and septic shock. Due to shock, she developed acute renal failure. She was intubated, ventilated, and received continuous veno-venous hemodialysis for renal failure. ST elevation was first observed on telemetry and subsequently confirmed on electrocardiogram. Marked ST elevation is present in the anterior leads with reciprocal ST depression in the inferior leads. A prolonged QT interval is also present. What is the most likely diagnosis?

Deep learning-based electrocardiogram rhythm and beat features for heart abnormality classification

BACKGROUND

Electrocardiogram (ECG) signal classification plays a critical role in the automatic diagnosis of heart abnormalities. While most ECG signal patterns cannot be recognized by a human interpreter, they can be detected with precision using artificial intelligence approaches, making the ECG a powerful non-invasive biomarker. However, performing rapid and accurate ECG signal classification is difficult due to the low amplitude, complexity, and non-linearity. The widely-available deep learning (DL) method we propose has presented an opportunity to substantially improve the accuracy of automated ECG classification analysis using rhythm or beat features. Unfortunately, a comprehensive and general evaluation of the specific DL architecture for ECG analysis across a wide variety of rhythm and beat features has not been previously reported. Some previous studies have been concerned with detecting ECG class abnormalities only through rhythm or beat features separately.

METHODS

This study proposes a single architecture based on the DL method with one-dimensional convolutional neural network (1D-CNN) architecture, to automatically classify 24 patterns of ECG signals through both rhythm and beat. To validate the proposed model, five databases which consisted of nine-class of ECG-base rhythm and 15-class of ECG-based beat were used in this study. The proposed DL network was applied and studied with varying datasets with different frequency samplings in intra and inter-patient scheme.

RESULTS

Using a 10-fold cross-validation scheme, the performance results had an accuracy of 99.98%, a sensitivity of 99.90%, a specificity of 99.89%, a precision of 99.90%, and an F1-score of 99.99% for ECG rhythm classification. Additionally, for ECG beat classification, the model obtained an accuracy of 99.87%, a sensitivity of 96.97%, a specificity of 99.89%, a precision of 92.23%, and an F1-score of 94.39%. In conclusion, this study provides clinicians with an advanced methodology for detecting and discriminating heart abnormalities between different ECG rhythm and beat assessments by using one outstanding proposed DL architecture.

Interobserver Variability Among Experienced Electrocardiogram Readers To Diagnose Acute Thrombotic Coronary Occlusion In Patients with Out of Hospital Cardiac Arrest: Impact of Metabolic Milieu and Angiographic Culprit

OBJECTIVES

We sought to evaluate interobserver concordance among experienced electrocardiogram (ECG) readers in predicting acute thrombotic coronary occlusion (ATCO) in the context of abnormal metabolic milieu (AMM) following resuscitated out of hospital cardiac arrest (OHCA).

METHODS

OHCA patients with initial shockable rhythm who underwent invasive coronary angiography (ICA) were included. AMM was defined as one of: pH < 7.1, lactate > 2 mmol/L, serum potassium < 2.8 or > 6.0 mEq/L. The initial ECG following ROSC but prior to ICA was adjudicated by 2 experienced readers using classic ST elevation myocardial infarction [STEMI] and expanded criteria and their combination to predict ATCO on ICA.

RESULTS

152 consecutive patients (mean age 58 years, 76% male) met inclusion criteria. AMM was present in 77%; and 42% had ATCO on ICA. Sensitivity, specificity, PPV, NPV using classic STEMI criteria were 50%, 98%, 94%, 72% (c-statistic 0.74); whereas for combined (STEMI + expanded) criteria they were 69%, 88%, 81%, 79% respectively (c-statistic 0.79). Inter-observer agreement (kappa) was 0.7 for classic STEMI criteria, and 0.66 for combined criteria. Agreement between readers was consistently higher when ATCO was absent and with NMM (kappa 0.78), but lower in AMM (kappa 0.6).

CONCLUSIONS

Despite experienced ECG readers, there was only modest overall concordance in predicting ATCO in the context of resuscitated OHCA. Significant interobserver variations were noted dependent on metabolic milieu and angiographic ATCO. These observations fundamentally question the role of the 12-lead ECG as primary triaging tool for early angiography among patients with OHCA.

Pulmonary embolism initially misdiagnosed as perimyocarditis in a young patıent

Pulmonary embolism is a common cardiovascular emergency. In case of delayed diagnosis and treatment morbidity and mortality is high. In this report, we presented a case of pulmonary embolism without apparent risk factors, which was initially misdiagnosed as peri/myocarditis.

Lung carcinoma paraneoplastic reactive regional pericarditis mimicking ST elevation myocardial infarct

ST-elevation myocardial infarction (STEMI) is a cardiac emergency. However, multiple clinical disorders can cause ST-elevation ECG changes, one of which is pericarditis. Regional pericarditis is a less known clinical phenomenon that can mimic STEMI. We report a case of poorly differentiated lung carcinoma associated reactive regional pericarditis mimicking inferior STEMI.

A deep learning algorithm for detecting acute myocardial infarction

BACKGROUND

Delayed diagnosis or misdiagnosis of acute myocardial infarction (AMI) is not unusual in daily practice. Since a 12-lead electrocardiogram (ECG) is crucial for the detection of AMI, a systematic algorithm to strengthen ECG interpretation may have important implications for improving diagnosis.

AIMS

We aimed to develop a deep learning model (DLM) as a diagnostic support tool based on a 12-lead electrocardiogram.

METHODS

This retrospective cohort study included 1,051/697 ECGs from 737/287 coronary angiogram (CAG)-validated STEMI/NSTEMI patients and 140,336 ECGs from 76,775 non-AMI patients at the emergency department. The DLM was trained and validated in 80% and 20% of these ECGs. A human-machine competition was conducted. The area under the receiver operating characteristic curve (AUC), sensitivity, and specificity were used to evaluate the performance of the DLM.

RESULTS

The AUC of the DLM for STEMI detection was 0.976 in the human-machine competition, which was significantly better than that of the best physicians. Furthermore, the DLM independently demonstrated sufficient diagnostic capacity for STEMI detection (AUC=0.997; sensitivity, 98.4%; specificity, 96.9%). Regarding NSTEMI detection, the AUC of the combined DLM and conventional cardiac troponin I (cTnI) increased to 0.978, which was better than that of either the DLM (0.877) or cTnI (0.950).

CONCLUSIONS

The DLM may serve as a timely, objective and precise diagnostic decision support tool to assist emergency medical system-based networks and frontline physicians in detecting AMI and subsequently initiating reperfusion therapy.

Not Every ST-Segment Elevation Is a STEMI

Electrocardiogram is fundamental to diagnose ST-segment elevation myocardial infarction in patients with chest pain, other consistent symptoms, and/or echocardiographic abnormalities. Nevertheless, physicians should remember that other conditions can cause an ST-segment elevation myocardial infarction–like electrocardiogram. We exemplify this warning describing the case of an electrocardiogram mimicking ST-segment elevation myocardial infarction caused by severe dysionia. (Level of Difficulty: Beginner.)

Electrocardiographic changes are strongly correlated with the extent of cardiac inflammation in mice with Coxsackievirus B3-induced viral myocarditis

OBJECTIVE

Viral myocarditis (VM) can induce changes in myocardial electrical conduction and arrhythmia. However, their relationship with myocarditis-associated arrhythmic substrates in the heart such as inflammation and fibrosis is relatively unknown. This we have analyzed in the present study.

METHODS

C3H mice were infected with 1×10⁵ plaque-forming units Coxsackievirus B3 (CVB3, n=68) and were compared with uninfected control mice (n=10). Electrocardiograms (ECGs) were recorded in all conscious mice shortly before sacrifice and included heart rate; P-R interval; QRS duration; QTc interval and R-peak amplitude of lead II and aVF. Mice were sacrificed at 4, 7, 10, 21, 35 or 49 days post-infection. Cardiac lesion size, calcification, fibrosis and cellular infiltration of CD45+ lymphocytes, MAC3+ macrophages, Ly6G+ neutrophils and mast cells were quantitatively determined in cross-sections of the ventricles. Putative relations between ECG changes and lesion size and/or cardiac inflammation were then analyzed.

RESULTS

Significant transient reductions in QRS duration and R-peak amplitude occurred between 4 and 14 days post-infection and returned to baseline values thereafter. The magnitude of these ECG changes strongly correlated to the extent of lymphocyte (days 7 and 14), macrophage (days 7 and 10) and neutrophil (days 7) infiltration. The ECG changes did not significantly correlate with lesion size and fibrosis.

CONCLUSION

VM induces transient changes in myocardial electrical conduction that are strongly related to cellular inflammation of the heart. These data show that even in mild VM, with relatively little cardiac damage, the inflammatory infiltrate can form an important arrhythmogenic substrate.

Prehospital Evaluation, ED Management, Transfers, and Management of Inpatient STEMI

ST elevation myocardial infarction diagnoses have reduced in number over the past 10 years; however, associated morbidity and mortality remain high. Societal guidelines focus on early diagnosis and timely access to reperfusion, preferably percutaneous coronary intervention (PCI), with fibrinolytics reserved for those who cannot receive timely PCI. Proposed algorithms recommend emergency department bypass in stable patients with a clear diagnosis to reduced door-to-balloon time. Emergency providers should limit their evaluation, focusing on life-threatening comorbidities, unstable vitals, or contraindications to a catheterization laboratory. In-hospital patients prove diagnostically challenging because they may be unable to express symptoms, and reperfusion strategies can complicate other diagnoses.

Likelihood of myocardial infarction, revascularization and death following catheterization laboratory activation in patients with vs. without both chest pain and ST elevation

BACKGROUND

Emergent cardiac catheterization laboratory activation (CCLA) for patients with suspected ST-elevation myocardial infarction (STEMI) is employed to expedite acute revascularization (AR). The incidence of false-positive CCLA, in which AR is not performed, remains high. The combination of chest pain (CP) and electrocardiographic ST elevation (STE) are the hallmarks of STEMI. However, CCLA is sometimes initiated for patients lacking this combination. The study objective was to quantify the difference in likelihood of AR and mortality in patients with vs. without both CP and STE.

METHODS

Retrospective analysis of 1621 consecutive patients for whom CCLA was initiated in a six-hospital network. We assessed the likelihood of acute myocardial infarction (AMI), presence of a culprit lesion (CL), performance of AR, and hospital mortality among patients with both CP and STE (+CP/+STE) compared with patients lacking one or both [non(CP/STE)].

RESULTS

87.0% of patients presented with CP, 82.4% with STE, and 73.7% with both. Among +CP/+STE patients, AMI was confirmed in 90.4%, a CL in 88.9%, and AR performed in 83.1%. The corresponding values among non(CP/STE) patients were 35.8, 31.9, and 28.1%, respectively (P < 0.0001 for each). Nevertheless, mortality among non(CP/STE) patients was three-fold higher than in +CP/+STE patients (13.3% vs. 4.5%; P < 0.0001), with non-coronary deaths 24-fold more likely.

CONCLUSION

Patients lacking the combination of CP and STE have a markedly lower likelihood of AMI and AR than +CP/+STE patients, but significantly higher mortality. Protocols aimed at rapid, focused evaluation of non(CP/STE) patients prior to CCLA are needed.

Triggering acute pancreatitis complicated with acute myocardial infarction by marijuana: a rare case report

Marijuana is a widely used illicit substance among young adults and its abuse has been reported worldwide. Marijuana is a rare trigger of acute myocardial infarction and acute pancreatitis. We present a 25-year-old man with acute pancreatitis subsequently complicated by acute ST-elevation myocardial infarction (STEMI), which was associated with marijuana abuse. This case highlights the need and importance of awareness among public about this rare but potentially lethal adverse effect. Also, it draws attention when clinicians confront patients with history of substance abuse, they should be alert to the possibility of concurrent occurrence of serious medical conditions that may be adverse effects of substance use. Acute pancreatitis with concurrent acute STEMI is a rare situation but is a challenge for many emergency physicians, and it can lead to trouble outcomes if it not be quickly diagnosed and properly managed. We demonstrate successful management in this complicated patient with primary angioplasty.

Prognostic Value of Troponin I in COVID-19 Patients

Introduction:

Corona Virus Disease (COVID -19) patients present mainly with respiratory manifestations and viral pneumonia. The cardiovascular system presentation includes early signs of acute myocardial injury. Cardiac troponin I (cTnI) is a gold-standard biomarker for necrosis and myocardial risk assessment.

Aim of the work:

This study aimed to assess the prognostic value of cTnI in COVID-19 patients.

Methodology:

We report a prospective study that included 92 COVID-19 patients admitted to the El Helal Hospital, Sohag, Egypt. Upon admission, routine investigations including cTnI, chest Computed Tomography (CT), and Electrocardiogram (ECG) were carried out. The patients admitted to the intensive care unit (ICU) also had echocardiography.

Results:

More than half of the patients (55.4%) were admitted to ICU; cTnI level was elevated in 30 patients (58.8%), of whom 17 died (56.7%). There were statistically significant differences regarding the relation between cTnI level, D-dimer and the need for ICU admission and death (p=0.001).

Conclusion:

We conclude that cardiac troponin I levels are a prognostic factor for ICU admission and mortality in COVID-19 patients.

STEMI Equivalents and Their Incidence during EMS Transport

Objective: The management of patients with ST-elevation myocardial infarction (STEMI) is time-critical, with a focus on early reperfusion to decrease morbidity and mortality. It is imperative that prehospital clinicians recognize STEMI early and initiate transport to hospitals capable of percutaneous coronary intervention (PCI) with a door-to-balloon time of ≤90 minutes. Three patterns have been identified as STEMI equivalents that also likely warrant prompt attention and potentially PCI: Wellens syndrome, De Winter T waves, and aVR ST elevation. The goal of our study was to assess the incidence of these findings in prehospital patients presenting with chest pain. Methods: We conducted a retrospective chart review from a large urban tertiary care emergency department. We reviewed the prehospital ECG, or ECG upon arrival, of 861 patients who were hospitalized and required cardiac catheterization between 4/10/18 and 5/7/19. Patients who had field catheterization lab activation by EMS for STEMI were excluded. If a prehospital ECG was not available for review, the first ECG obtained in the hospital was used as a proxy. Each ECG was screened for aVR elevation, De Winter T waves, and Wellens syndrome. Results: Of 278 charts with prehospital ECGs available, 12 met our criteria for STEMI equivalency (4.4%): 6 Wellens syndrome and 6 aVR STEMI. There were no cases of De Winters T waves. Of 573 charts with no prehospital ECG available, 27 had initial hospital ECGs that met our STEMI equivalent criteria (4.7%): 7 Wellens syndrome and 20 aVR STEMI. Again, there were no cases of De Winters T waves. Conclusions: These preliminary data suggest that there are significant numbers of patients whose prehospital ECG findings do not currently meet criteria for field activation of the cardiac catheterization lab, but who may require prompt catheterization. Further studies are needed to look at outcomes, but these results could support the need for further education of prehospital clinicians regarding recognition of these STEMI equivalents, as well as quality initiatives aimed at decreasing door-to-balloon time for patients with STEMI equivalents.